• Thromboembolic Disease (TED) in Trauma Patients

     
     
     
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    Deep vein thrombosis is a significant complication in patients that have undergone traumatic injury.  Trauma patients have the risk of having a deep vein thrombosis in the range of 8 – 60 percent, dependant on adequate prophylaxis.

    The type of LMWH at this time is provocative in that the only randomized prospective trial by William Geerts demonstrated superiority of 40 mg bid of Enoxaparin versus Unfractioned Heparin (UFH) bid.  In light of this study, there is no current recommendation of UFH by the ACCP.  For trauma patients, however, a different study, the 611 trial, demonstrated equal efficacy between UFH plus mechanical devices as compared to Enoxaparin 30mg bid.  

    The current guidelines from the American College of Chest Physicians (ACCP) 2008 recommend:

    (Prevention of Venous Thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest June 2008 133:6 suppl 381S-453S; doi:10.1378/chest.08-0656:)

    Trauma

    For all major trauma patients, we recommend routine thromboprophylaxis if possible (Grade 1A).

    For major trauma patients in the absence of a major contraindication, we recommend that clinicians use LMWH thromboprophylaxis starting as soon as it is considered safe to do so (Grade 1A). An acceptable alternative is the combination of LMWH and the optimal use of a mechanical method of thromboprophylaxis (Grade 1B).

    For major trauma patients, if LMWH thromboprophylaxis is contraindicated due to active bleeding or high risk for clinically important bleeding, we recommend that mechanical thromboprophylaxis with IPC, or possibly with GCS alone, be used (Grade 1B). When the high bleeding risk decreases, we recommend that pharmacologic thromboprophylaxis be substituted for or added to the mechanical thromboprophylaxis (Grade 1C).

    In trauma patients, we recommend against routine DUS screening for asymptomatic DVT (Grade 1B). We do recommend DUS screening in patients who are at high risk for VTE (eg, in the presence of a SCI, lower-extremity or pelvic fracture, or major head injury), and who have received suboptimal thromboprophylaxis or no thromboprophylaxis (Grade 1C).

    For trauma patients, we recommend against the use of an IVC filter as thromboprophylaxis (Grade 1C).

    For major trauma patients, we recommend the continuation of thromboprophylaxis until hospital discharge (Grade 1C).

    For trauma patients with impaired mobility who undergo inpatient rehabilitation, we suggest continuing thromboprophylaxis with LMWH or a VKA (target INR, 2.5; range, 2.0 to 3.0) (Grade 2C).                                                                              

     

    Acute Spinal Cord Injury

    For all patients with acute SCI, we recommend that routine thromboprophylaxis be provided (Grade 1A).

    For patients with acute SCI, we recommend thromboprophylaxis with LMWH, commenced once primary hemostasis is evident (Grade 1B). Alternatives include the combined use of IPC and either LDUH (Grade 1B) or LWMH (Grade 1C).

    For patients with acute SCI, we recommend the optimal use of IPC and/or GCS if anticoagulant thromboprophylaxis is contraindicated because of high bleeding risk early after injury (Grade 1A). When the high bleeding risk decreases, we recommend that pharmacologic thromboprophylaxis be substituted for or added to the mechanical thromboprophylaxis (Grade 1C).

    For patients with an incomplete SCI associated with evidence of a spinal hematoma on CT or MRI, we recommend the use of mechanical thromboprophylaxis instead of anticoagulant thromboprophylaxis at least for the first few days after injury (Grade 1C).

    Following acute SCI, we recommend against the use of LDUH alone (Grade 1A).

    For patients with SCI, we recommend against the use of an IVC filter as thromboprophylaxis (Grade 1C).

    For patients undergoing rehabilitation following acute SCI, we recommend the continuation of LMWH thromboprophylaxis or conversion to an oral VKA (INR target, 2.5; range, 2.0 to 3.0) (Grade 1C).

    In light of these findings, we recommend bid dosing of LMWH alone or a combination of mechanical plus chemical prophylaxis, either bid LMWH, or tid UFH for high risk trauma patients.

    Vena Caval Filters are indicated for high risk patients who have contra indication or full long term anticoagulation with emergent TED.

    The advent and use of newer agents such as Fondiparinox or the new oral Anti XA agents are yet to be standard of care due to no large studies advocating their use, however, they hold great promise in the area of extended prophylaxis (2 – 4 weeks) to prevent the 60% of TED that occur post injury.

    Articles:

    CHEST June 2008 vol. 133 no. 6 suppl 381S-453S

    CHEST February 2009 vol. 135 no. 2 513-520

    Handbook of Evidence-Based Critical Care 2010, Part2, 245-252

    Websites:

    www.thromboadviser.com

    www.preventdvt.org

    www.nhlbi.nih.gov

    www.thrombosisguidelinesgroup.be

     Author: Enrique Ginzburg, MD (2011)